CurrentKaiser PermanentePolicy No. 01-56

Clinical Review Orthopedic Spine Neurosurgery Spine Referrals For Back Pain Spine Conditions Ga

Defines criteria for approving referrals to Orthopedic Spine or Neurosurgery Spine specialists for cervical, thoracic, and lumbosacral spine conditions in the Georgia region; excludes emergent neurosurgery with red flags, brain/CNS tumors, bleeds, spinal tumors, trauma, and infections. Provides required imaging, prior conservative treatment, and exceptions that are frequently approved.

Policy Summary

PayerKaiser Permanente

PolicyClinical Review Orthopedic Spine Neurosurgery Spine Referrals For Back Pain Spine Conditions Ga

Policy CodePolicy No. 01-56

Change TypeReviewed/Revised (3/14/2024)

Effective DateJan 1, 2021

Next Review Date

Key ActionFor non-emergent referrals that do not meet the frequently approved indications, ensure all 'Referrals Requiring All Criteria' are documented and obtain approval of the Chief of Service (COS) of Pain Management or designee.

SourceLink

POLICY UPDATE CHANGES

Document reviewed/revised with last revision date 3/14/2024 per header.

No material clinical or coverage changes reported in this update.

10+Frequently Approved Indications Listed

7Required 'All' Criteria for other referrals

3/12Imaging recency thresholds (months)

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Coverage Summary

Scope: Defines criteria for approving referrals to Orthopedic Spine or Neurosurgery Spine specialists for cervical, thoracic, and lumbosacral spine conditions in the Georgia region. Excludes emergent neurosurgery with red flags, brain/CNS tumors, bleeds, spinal tumors, trauma, and infections. Provides required imaging recency, prior conservative treatment, frequently approved indications, and exceptions. Policy Number: No. 01-56. Subject: Orthopedic and Neurosurgery Spine Referrals for Back Pain and Spine Conditions. Status: CURRENT. Effective Date: 2021-01-01. Last Review: 2024-03-14.

Key thresholds and quick facts

Physical Therapy Trial WindowTried physical therapy within last 6 months

Imaging Age RequirementPlain X‑ray and MRI of affected spine ≤ 12 months (unless significant symptom change)

MRI/CT Recency for specific conditionsMRI or CT < 3 months for myelopathy, spinal fracture (non‑VCF), and severe scoliosis films

Failed Pain Management Trial WindowFailed trial of treatment with Pain Management within last 3 months

Frequently Approved Indications Listed10+ specific frequently approved referral reasons (e.g., myelopathy, cauda equina, discitis, hardware fracture, post‑op follow‑up)

Required 'All' Criteria for other referrals7 required items must all be met for non‑emergent/other referrals

Imaging Recency ThresholdsTwo key thresholds used: 3 months and 12 months

Medical Necessity / Referral Criteria

Referrals Frequently Approved

Referrals to Orthopedic Spine or Neurosurgery Spine are frequently approved for the following:

Previously approved pain management referral: Previously approved referral from one of the pain management providers
Cauda equina (emergent): Clinical symptoms, exam, and MRI or CT scan consistent with cauda equina needing an emergent evaluation
Myelopathy (weakness, gait disturbance, hyperreflexia) WITH MRI or CT less than 3 monthsMRI/CT < 3 months
Clinical syndrome defined as weakness, gait disturbance, hyperreflexia; requires MRI/CT < 3 months for referral approval

Provider Actions & Documentation Requirements

Prior Authorization

Approval required for non-exempt referrals

For non-emergent referrals that do not meet the frequently approved indications, ensure all 'Referrals Requiring All Criteria' are documented and obtain approval of the Chief of Service (COS) of Pain Management or their designee before referral to Orthopedic Spine or Neurosurgery Spine.

Documentation Required

Imaging and Treatment Documentation

Include documentation of required imaging and treatments when submitting referrals: plain X‑ray and MRI of the affected spine ≤ 12 months (unless significant symptom change); MRI or CT < 3 months where specifically noted (e.g., myelopathy, spinal fracture, severe scoliosis). Also document a trial of physical therapy within the last 6 months, concordant MRI findings, and a failed trial of treatment with Pain Management within the last 3 months.

Plain X‑ray and MRI ≤ 12 months (unless symptoms significantly changed)
MRI/CT < 3 months when specified (myelopathy, certain fractures, severe scoliosis)

Coding

No codes listed

Background & References

This QRM document guides appropriate referrals to Orthopedic and Neurosurgery Spine specialists for surgical management of spine conditions and common causes of back pain. It explicitly excludes referrals for emergent neurosurgery conditions with red flag symptoms and for brain tumors, CNS bleeds, spinal tumors, trauma, or infections; such cases should be referred emergently as clinically indicated. The document lists frequently approved indications (e.g., myelopathy with recent imaging, non-compression spinal fractures with recent imaging, new myelomalacia, post-operative surgeon follow-up, discitis, epidural/spinal hematoma, hardware fracture, and severe scoliosis with recent scoliosis films) and provides a separate set of required criteria for non-emergent or other referrals (including use of the Back Pain Algorithm, physical therapy trial, imaging requirements, concordant MRI findings, and failed pain management trial). It references external and internal guidance: MCG 24th Ed. - Low Back Pain and Lumbar Spine Conditions - Referral Management RMG: R-0056 and TSPMG Clinical Practice Guidelines for Pain Management Referrals - November 2015, and notes coordination with internal Pain Management referral guidance and approval by the Chief of Service (COS) of Pain Management or designee for non-exempt referrals.

Referenced Guideline	Internal Guideline
MCG 24th Ed. - Low Back Pain and Lumbar Spine Conditions - Referral Management RMG: R-0056	TSPMG Clinical Practice Guidelines for Pain Management Referrals - November 2015

Myelopathy: Clinical syndrome including weakness, gait disturbance, hyperreflexia; referral approval requires MRI or CT less than 3 months.

Vertebral compression fractures: Rarely require surgery; some patients may benefit from kyphoplasty or vertebroplasty performed by Interventional Radiology. Consider referral to Pain Management or Pain MD Advice for these patients.

Revision History

3/14/2024revisedLatest

Document header indicates Reviewed/Revised with last revision date 3/14/2024; change noted as non-material per brief.

Policy Summary

PayerKaiser Permanente

PolicyClinical Review Orthopedic Spine Neurosurgery Spine Referrals For Back Pain Spine Conditions Ga

Policy CodePolicy No. 01-56

Change TypeReviewed/Revised (3/14/2024)

Effective DateJan 1, 2021

Next Review Date

SourceLink

On This Page

Spinal fracture (excluding VCF): Spinal Fracture (NOT vertebral compression fractures) WITH MRI or CT less than 3 monthsMRI/CT < 3 months

Vertebral compression fractures rarely require surgery; consider kyphoplasty/vertebroplasty or Pain Management referral

New myelomalacia on recent imaging: Recent MRI or CT scan with a finding of new myelomalacia (spinal cord signal changes)

Post-operative follow-up by spine surgeon: Spine surgeon request for post-operative follow-up

Document surgeon request

Epidural or spinal hematoma: Epidural or Spinal Hematoma

Hardware fracture: Hardware Fracture

Severe scoliosis with recent films: Severe scoliosis WITH scoliosis films, less than 3 monthsscoliosis films < 3 months

Referrals Requiring All Criteria (Non-emergent / Other referrals)

For all other (non-emergent) referrals to Orthopedic Spine or Neurosurgery Spine, all of the following criteria must be met:

Referrals Requiring All Criteria

Back Pain Algorithm Followed (this algorithm also pertains to the cervical and thoracic spine)
Physical therapy trial: Tried Physical Therapy in the last 6 monthswithin 6 months
Plain X-ray and MRI recency: Plain X-ray and MRI of the affected spine required<= 12 months (unless significant symptom change)
12 months old or less as long as no significant symptom changes
Rapid progression despite conservative care: Current clinical symptoms and exam consistent with rapid progression of symptoms despite conservative treatment
Concordant MRI findings
Failed Pain Management trial: Failed trial of treatment with Pain Management in the last 3 monthswithin 3 months
COS of Pain Management approval: Requires approval of the COS of Pain Management, or their designee

Physical therapy trial within last 6 months

Concordant MRI findings

Failed Pain Management trial within last 3 months

Documentation Required

Emergent Red-Flag Handling

Do not apply these referral criteria to emergent neurosurgery conditions with red flag symptoms (e.g., cauda equina, brain/CNS tumors, CNS bleeds, spinal tumors, trauma, infections). Such patients should be referred emergently as clinically indicated.

Billing Rule

Post-operative follow-up

Referrals requested by a spine surgeon for post-operative follow-up are frequently approved. Include documentation that the referral was requested by the spine surgeon when submitting the referral.

Denial Risk

Referrals lacking required conservative therapy or imaging

Referrals that lack required conservative therapy (e.g., recent physical therapy), appropriate imaging, or a recent pain management trial may be denied or redirected to Pain Management Advice. Consider Pain MD Advice if the referral does not meet criteria.